Public private partnership in Iran s Health Care System

1. Public private partnership in Iran�s Health Care System By: A. Pourreza; M. Momensaraie TUMS & SSO Islamic Republic of Iran Key Words: contract, financing, health system, reform goals

2. Definition What the seller/provider provides, What the buyer/purchaser pays, Delivery and payment dates The time period of agreement, Renewal positions (if any), Penalties for nonperformance, and Process of resolve disagreements.

3. Assumptions for contracting out Effective Management in private sector, Sufficient number of providers allows for competition, Provider competition enhances efficiency, The benefits exceed the costs, The contractor (MOH) has the capacity to design and manage contracts/contractual arrangements.

4. Continue Strengthening service delivery capacity of private sector, Increases allocative and technical efficiency), Promotes transparency in trading and decentralization, Encourages planning, monitoring and evaluation, and management practices, Implement changes in Who-does-What

5. In developing countries Enough potential providers exist for creation of competition, Provider competition, without any change on the purchasing side, can enhance efficiency, Government has adequate capacity to enter and manage contractual relationships with the private sector.

6. Successful contracting In public sector: Do there is expertise to develop specifications, make contracting decisions, write contract, and oversee compliance? Do public hospitals have significant autonomy and independence which are essentials to a successful contract, Are there performance-based incentives and accountability for managers in order to contract effectively.

7. Continue In private sector and wider environment: -The existence of willing/able to pay for private care groups, - The absence of great inequities, - Strong professional ethics, - Informed consumers and active consumer organizations, - Appropriate incentives and regulatory structure for health care providers, - relatively high standards of care in the government sector.

8. Contracting effects on: Access: - physical access: -quantity of services provided, population coverage, and availability of interventions. - financial access: - insurance coverage, income /affordability

9. Continue: Equity: -equity in access, financing or health outcomes, Strategies to improve equity: 1-establishing contractual arrangements that specifically encourage providers to serve the poor and underserved; 2-contracting with private providers in areas that are of predominantly poor (geographic targeting); 3- contracting out services that are of most benefit to the poor and underserved.

10. Continue: Lack of sufficient evidence from comparative studies; it is doubtful that contracted private providers are more successful in improving equity than the public providers. Contracting resulted to improving access and promoting equity through extension of subsidized services to the poor and vulnerables.

11. Quality A major goal of health systems: - improving quality helps cost containment, - improves patients� satisfaction and, - indirectly enhances equity initiatives in health care delivery. Tendency for focus on quantity and access, makes it difficult to measure changes in quality.

12. Continue If there is no linkage between payment to contractors and the quality of their performance, providers have little incentives to improve quality. It is not clear that contracting out improves quality of care compared with direct public provision, because: - First; quality is undefined or inconsistently defined across different contracting projects. -Second; there have usually been no control group in evaluation.

13. Efficiency Contracting can be used to increase efficiency: Lower unit cost; - cost per admission in some autonomous hospitals (300JD as compare to over 1500 JD in private hospitals without contracts. Increases both technical efficiency (by saving resources), and allocative efficiency (by redirecting resources ). Efficiency more than equity motivates policy makers to out sourcing.

14. Contracting out and Iran�s Health Care System Socio-economic development plan (the third), 1999, Article 192 Circular 88 While the Article 192 emphasized mainly on privatization and contracting out clinical services, there was no clear cut between clinical and non-clinical services, in terms of contracting out, in Circular 88. The Universities of Medical Sciences Utilized the guideline they preferred, and consequently; A very sophisticated environment, particularly in terms of: - performance evaluation, - homogeneous information generation, and - policy continuity, has taken place.